Following the investigation into the Clapham Junction accident in 1989 Sir Anthony Hidden suggested that development of a ‘positive safety culture’ was the key to improving the safety of Britain’s railway network. It has become generally accepted that a high proportion of accidents, incidents and near misses on the railways follow unsafe acts by people, whether frontline workers or managers.

The Southall and Ladbroke Grove train crashes that happened in September 1997 and October 1999 respectively, led to three separate public inquiry reports: one for each crash and a report on Automatic Train Protection. The inquiries took a fundamental look at the generic issues surrounding safety in the British Railway Industry. A principle conclusion focused on the improvement of safety management, specifically safety culture:

“Achievement of an improved safety culture on the railways is at the core of the whole programme of change initiated by Lord Cullen’s Inquiries . . . if an organisation has the right culture in place it will find the right people and the right technology to deliver safe and effective performance.” 

“…the need for a positive safety culture is the most fundamental thought before the inquiry.”

The reports resulted in 295 recommendations, setting 'a necessary and challenging criteria to change the state of the railways’. A section of the recommendations fell under the title ‘Culture, Safety Leadership and Health and Safety Management’ which presents twenty-five recommendations relating to the internal structures of companies, safety culture, and the management of health and safety. It also includes coverage of the use of risk assessments and safety cases. The recommendations were aimed at securing improvements in the following areas:

• Safety auditing processes,
• Fault reporting and maintenance,
• Risk assessment,
• Application of a railway safety case regime,
• Safety leadership and communication in companies.

Within the UK Rail Industry, privatisation gave rise to over fifty franchises, with numerous sub-contractors having responsibility for sections of the railway. When plans for privatisation were first documented, the HSE expressed concerns that safety might suffer as a result. In 2002, an HSC review of progress on the public inquiry recommendations noted that the development of an enhanced safety culture across the rail industry is still inconsistent, with some companies improving at a greater pace than others.